197609362-10-14-2023-31-AS-AALR-CWLUFG-20231014153243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609362
Report Date: 10/14/2023
Date Signed: 10/14/2023 03:33:08 PM

Document Has Been Signed on 10/14/2023 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	IVY PARK AT BURBANK		FACILITY NUMBER:	197609362
ADMINISTRATOR:	DAWN SMITH		FACILITY TYPE:	740
ADDRESS:	2721 WILLOW STREET		TELEPHONE:	(818) 954-9500
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY:	130	CENSUS: 88	DATE:	10/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Krista Cheshire, Activity Director		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPAs) Antonia Alvizar and Gary Tan arrived at the facility at 9:00 AM today to conduct a One (1) year Required visit. LPAs initially met with Activity Director, Krista Cheshire, later joined Administrator, Dawn Smith and explained the purpose of this visit. The facility has an approved mitigation and infection control plan on file. LPA Alvizar and LPA Tan utilized the Compliance and Regulatory Enforcement (CARE) tools, and a tour of the physical plant was conducted at 11:00 AM with Krista Cheshire and Keith Bernabe during today visit and observed the following: The facility has a fire clearance for one hundred (100) non ambulatory of which, 30 maybe bedridden. Hospice waiver for twelve (12) residents. Delayed egress is approved for Dementia Unit on second floor. Required postings were observed in the entry area. The facility's smoke alarms are hard wired as back up and tests are done on a monthly basis. Fire drill was last conducted on September 03, 2023. There are fire extinguishers throughout the facility hallways on all eight (8) floors, all extinguishers were last serviced on January 05, 2023. The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette, and physical distancing) posted. The PPE supplies is located at the Executive Director office and Medication Room upon entry there is hand sanitizers by the elevator and sign in sheet at the time of visit. The facility maintains a temperature of 75 degrees Fahrenheit. All eight (8) floors have a mini activity room located at the end of each floor. Continued on LIC809C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT BURBANK	FACILITY NUMBER: 197609362
	VISIT DATE: 10/14/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Bedrooms: At 11:30 AM LPAs were able to observe ten (10) random rooms from each floor. All bedrooms observed to be appropriately furnished with
sufficient lighting. LPAs observed appropriate bed linen and comforters on all beds. All bedrooms observed to be clean and clear from obstruction.
Bathroom: At 11:30AM LPAs observed ten (10) bathrooms located in the bedrooms. LPAs observed appropriate grab bars located in the shower and around the toilet. The water temperature measured in range of 113.7 between 118.0 degrees Fahrenheit. Non-skid mats were located in the shower. Bathrooms are stocked and equipped with soap and paper towels. Hand towels are not shared.
Laundry Room: At 11:10 AM LPAs observed the laundry rooms located on the and first floor for commercial laundry, fifth and sixth floors for resident clothing residents have access to the laundry area to do their own laundry, clean and clear from obstruction and storing laundry supplies.
Medications: LPA observed two (2) medication carts at 11:15 AM stored in the medication room on the first floor to be locked and storing medication and inaccessible to residents. The refrigerator was observed to be doubled locked storing narcotic medications. The facility has first aid kits located in the medication room.
Theater room, living/game room on each floor, and common areas: At 11:45 AM LPAs observed these areas to be appropriately furnished with tables and chairs and adequate lighting. Observed to be neat and clean. The facility has a gym on the eighth (8) floor currently being used by a resident at the time of inspection. The theater room is located on the 8th floor and was unoccupied at the time of inspection. LPAs observed two (2) outdoor patio areas, one located outside the lobby, the second behind the Private Dining Room, and the surrounding grounds of the facility which were clean and clear from debris and obstruction. These areas are equipped with owing and tables with chairs for seating and additional tables and chairs for lounging. LPAs observed a Fire Department Fire Protection Equipment Performance Report dated 03/24/2023 to have passed, the fire alarm system are hard wired and interconnected throughout facility and tested internally every month. The facility has a fire sprinkler system. No body of water was observed or located on the premises. No deficiencies cited, exit interview conducted, and a copy of report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2